Marjorie Wood
PFD Report
Partially Responded
Ref: 2016-0161
Coroner's Concerns (AI summary)
There is a lack of clear understanding about the legal status of individuals in care homes, which can negatively impact their care and treatment.
View full coroner's concerns
The concerns noted by the Court during the course of the Inquest are as follows: Whilst there was no evidence in this case that the lack of clarity or knowledge in this particular case made & difference to the deceased, it is important that there is full understanding of the legal status of an individual who is in a care home as this may impact on their care and treatment needs_
Responses
Action Taken
Kingsley Healthcare Group has reviewed its Deprivation of Liberty Safeguards Policy and Procedure and has provided further training and supervision to staff and checked for completed application and authorization records during audits. (AI summary)
Kingsley Healthcare Group has reviewed its Deprivation of Liberty Safeguards Policy and Procedure and has provided further training and supervision to staff and checked for completed application and authorization records during audits. (AI summary)
View full response
Dear liberty "Peg: Aithed Nursing
Scope Anyone dealing with people aged 18 year or over who has a mental disorder and who lacks the ability to give consent, who may be deprived oftheir liberty Policy The Deprivation of Liberty Safeguards Code of Practice, published by the Ministry of Justice, will be followed in respect of all Service Users A link to the Code of Practice can be founa at the end of this document: The Deprivation of Liberty Safeguards Forrns Record Keeping Guide for Managing Authorities in England (Hospitals and Care Homes) will be used to manage DOLS A link to these forms can be found at the end of this document This policy should be read in conjunction with the following policies (where applicable): Supervisory Bodv/Local Authority Policy and Procedure_ Mental Capacity Act 2005 Policy and Procedure Procedure Good practice indicates that the care home should take reasonable steps to try and avoid a deprivation of liberty occurring steps include Effective Care Planning that is reviewed regularly; Involvement of the Service User' s family in decision making; Exploring alternative and less restrictive ways of providing care consistent with protecting the person from harm; Assessing the person'$ capacity to make decisions about their care Where a Service User may be being deprived of their liberty, the managing authority has responsibility for applying for an authorisation of the deprivation. In the case of the Service User in an NHS hospital, the managing authority IS the NHS hospital In the case ofthe Service User being in a care home Or private hospital, the managing authority is the person registered as manager under part 2 of the Care Standards Act 2000 The managing authority should apply to supervisory body for the area in which the person IS ordinarily resident: In England and Wales, for people in care homies, the supervisory body Is the local authority For people in NHS hospitals in England the supervisory body Is also the local authority For people in hospitals In Wales, the supervisory body is the Local Health Board in the area where the hospital IS situated In applying for an authorisation the care home or hospital should use the forms and procedures produced for the purpose of application and management of2 Deprivation cf Liberty Safeguard authorisation which are contained in The Deprivation of Liberty Safeguards Forms and Record Keeping for Managing Authorities in England (Hospitals and Care Homes) which can be fourd in the Useful Documents section of the QCS system (in your Quick Links box) A recent review of these forms has reduced the number of forms necessary and these can be found at the Iink below. These revised forms Include a new form for informing the Coroner in the event ofa death: The managing authority must keep a written record of each application, reasons for the request and authorisation: This should be recorded centrally within the home and in each individual's care plan: The managing authority should tell the Service User $ family, friends and carers, and any Independent Mental Capacity Advocate (if there Is one already involved) that it applied for Kingsley Healthcare I5 trading narle Tor Kiigsiev ( are Homes uimited (Reg No. 4446972}, Regal Healthcare Properties Limited No. 476,494), Country Retirement & Nursing Homes Limited No 37909531, Akther healthtire Linuted Reg No. 6321545), Althea Healthcare Properties Limited (Reg: No 6368379) Hestia Healthcare Linited (Reg- No 6321543} Ali corranzs Ieg lered !r. Englard Rejistered Office" Silk Cutters House, School Road, Lowestoft; Suffolk NR33 9NA and These being the guide has (Reg; (Req
an authorisation, unless it is impractical or impossible to do so,or it would be undesirable in the Interest of the Service User's health or safety Ifa standard authorisation is given, the supervisory body must appoint a relevant person's representative (RPR) to maintain contact and support the person. The managing authority must make sure the person and their RPR understand the nature Of the authorisation: Where someone dies whilst subject to a Deprivation of Liberty authorisation, the care home or hospital should report the death to the Coroner, In accordance with the Coroners and Justice Act 2009 and subsequent guidance given by the Chief Coroner In December 2014 regarding deaths of people deemed to be in state detention: There is a Iink at the end of this policy to statutory forms which includes a form for reporting a death to the Coroner There is also a link to the Chief Coroner's guidance regarding people subject to Deprivation of Liberty Safeguards Ms Cank had previously completed training in relation to MCA and DoLS. She has undeigone supervision with her line manager in respect of the concerns raised bl your investigation and IS due to undertake further training: Timperley had failed to follow policy and written record of each application, reasons for the request and authorisation: This informatior IS now checked during audits of the home and is available on shared file to line managers. hope that the information provided offers assurances that the findings of your investigations and the areas vou have highlighted for the prevention of future deaths have prompted action and been the focus ofour continued commitment to providing quality care for Individuals living in our homes_
Scope Anyone dealing with people aged 18 year or over who has a mental disorder and who lacks the ability to give consent, who may be deprived oftheir liberty Policy The Deprivation of Liberty Safeguards Code of Practice, published by the Ministry of Justice, will be followed in respect of all Service Users A link to the Code of Practice can be founa at the end of this document: The Deprivation of Liberty Safeguards Forrns Record Keeping Guide for Managing Authorities in England (Hospitals and Care Homes) will be used to manage DOLS A link to these forms can be found at the end of this document This policy should be read in conjunction with the following policies (where applicable): Supervisory Bodv/Local Authority Policy and Procedure_ Mental Capacity Act 2005 Policy and Procedure Procedure Good practice indicates that the care home should take reasonable steps to try and avoid a deprivation of liberty occurring steps include Effective Care Planning that is reviewed regularly; Involvement of the Service User' s family in decision making; Exploring alternative and less restrictive ways of providing care consistent with protecting the person from harm; Assessing the person'$ capacity to make decisions about their care Where a Service User may be being deprived of their liberty, the managing authority has responsibility for applying for an authorisation of the deprivation. In the case of the Service User in an NHS hospital, the managing authority IS the NHS hospital In the case ofthe Service User being in a care home Or private hospital, the managing authority is the person registered as manager under part 2 of the Care Standards Act 2000 The managing authority should apply to supervisory body for the area in which the person IS ordinarily resident: In England and Wales, for people in care homies, the supervisory body Is the local authority For people in NHS hospitals in England the supervisory body Is also the local authority For people in hospitals In Wales, the supervisory body is the Local Health Board in the area where the hospital IS situated In applying for an authorisation the care home or hospital should use the forms and procedures produced for the purpose of application and management of2 Deprivation cf Liberty Safeguard authorisation which are contained in The Deprivation of Liberty Safeguards Forms and Record Keeping for Managing Authorities in England (Hospitals and Care Homes) which can be fourd in the Useful Documents section of the QCS system (in your Quick Links box) A recent review of these forms has reduced the number of forms necessary and these can be found at the Iink below. These revised forms Include a new form for informing the Coroner in the event ofa death: The managing authority must keep a written record of each application, reasons for the request and authorisation: This should be recorded centrally within the home and in each individual's care plan: The managing authority should tell the Service User $ family, friends and carers, and any Independent Mental Capacity Advocate (if there Is one already involved) that it applied for Kingsley Healthcare I5 trading narle Tor Kiigsiev ( are Homes uimited (Reg No. 4446972}, Regal Healthcare Properties Limited No. 476,494), Country Retirement & Nursing Homes Limited No 37909531, Akther healthtire Linuted Reg No. 6321545), Althea Healthcare Properties Limited (Reg: No 6368379) Hestia Healthcare Linited (Reg- No 6321543} Ali corranzs Ieg lered !r. Englard Rejistered Office" Silk Cutters House, School Road, Lowestoft; Suffolk NR33 9NA and These being the guide has (Reg; (Req
an authorisation, unless it is impractical or impossible to do so,or it would be undesirable in the Interest of the Service User's health or safety Ifa standard authorisation is given, the supervisory body must appoint a relevant person's representative (RPR) to maintain contact and support the person. The managing authority must make sure the person and their RPR understand the nature Of the authorisation: Where someone dies whilst subject to a Deprivation of Liberty authorisation, the care home or hospital should report the death to the Coroner, In accordance with the Coroners and Justice Act 2009 and subsequent guidance given by the Chief Coroner In December 2014 regarding deaths of people deemed to be in state detention: There is a Iink at the end of this policy to statutory forms which includes a form for reporting a death to the Coroner There is also a link to the Chief Coroner's guidance regarding people subject to Deprivation of Liberty Safeguards Ms Cank had previously completed training in relation to MCA and DoLS. She has undeigone supervision with her line manager in respect of the concerns raised bl your investigation and IS due to undertake further training: Timperley had failed to follow policy and written record of each application, reasons for the request and authorisation: This informatior IS now checked during audits of the home and is available on shared file to line managers. hope that the information provided offers assurances that the findings of your investigations and the areas vou have highlighted for the prevention of future deaths have prompted action and been the focus ofour continued commitment to providing quality care for Individuals living in our homes_
Sent To
- Kingsley Care Home
- Timperley Care Home
Response Status
Linked responses
1 of 2
56-Day Deadline
20 Jun 2016
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 18th April 2016 [ concluded the Inquest into the death of Marjorie Wood date of birth 22.08.1918 who died on the 02.12.2015. The cause of death was la)Bronchopneumonia 2) Advanced Alzheimer' s Dementia and CVA recordcd a natural causes conclusion: CIRCUMSTANCES OF THE DEATH The Court heard evidence that the deceased had history of dementia and was residing at Timperley Care Home. She had been found deceased at the care home on the 02.12.2015 The death was reported to HM Coroner as she was said to be subject to a Deprivation of Liberty Safeguarding Application (DOLS) An Inquest was opened and evidence requested from Timperley Care Home. Several requests for evidence were ignored by the Care Home SO a full had to take place_ At the Inquest the Manager was unable to confirm whether in fact the deceased was subject to DOLS application as Timperley had no information from the Local Authority as to whether this had been authorised. No efforts had been made to contact the Local Authority to obtain this information by the Care Home: Ij hearing
They did not know whether the deceased was or was not subject to a DOLS or whether this made any difference to the care and treatment she required. DOLS application had in fact been in place since August 2015_ CQRONERISCONCERNS The concerns noted by the Court during the course of the Inquest are as follows: Whilst there was no evidence in this case that the lack of clarity or knowledge in this particular case made & difference to the deceased, it is important that there is full understanding of the legal status of an individual who is in a care home as this may impact on their care and treatment needs_ ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report, namely by 20.06.2016. I, the coroner; may extend the period: Your response must contain details of action taken Or proposed to be taken; setting out the timetable for action. Otherwise you must explain why no action is proposed: COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mrs Wood am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me, the coroner; at the time ofyour response, about the release or the publication of your response by the Chief Coroner_ 25.04.2016 Joanne Kearsley Area Coroner days
They did not know whether the deceased was or was not subject to a DOLS or whether this made any difference to the care and treatment she required. DOLS application had in fact been in place since August 2015_ CQRONERISCONCERNS The concerns noted by the Court during the course of the Inquest are as follows: Whilst there was no evidence in this case that the lack of clarity or knowledge in this particular case made & difference to the deceased, it is important that there is full understanding of the legal status of an individual who is in a care home as this may impact on their care and treatment needs_ ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report, namely by 20.06.2016. I, the coroner; may extend the period: Your response must contain details of action taken Or proposed to be taken; setting out the timetable for action. Otherwise you must explain why no action is proposed: COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mrs Wood am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me, the coroner; at the time ofyour response, about the release or the publication of your response by the Chief Coroner_ 25.04.2016 Joanne Kearsley Area Coroner days
Circumstances of the Death
The Court heard evidence that the deceased had history of dementia and was residing at Timperley Care Home. She had been found deceased at the care home on the 02.12.2015 The death was reported to HM Coroner as she was said to be subject to a Deprivation of Liberty Safeguarding Application (DOLS) An Inquest was opened and evidence requested from Timperley Care Home. Several requests for evidence were ignored by the Care Home SO a full had to take place_ At the Inquest the Manager was unable to confirm whether in fact the deceased was subject to DOLS application as Timperley had no information from the Local Authority as to whether this had been authorised. No efforts had been made to contact the Local Authority to obtain this information by the Care Home: Ij hearing
They did not know whether the deceased was or was not subject to a DOLS or whether this made any difference to the care and treatment she required. DOLS application had in fact been in place since August 2015_
They did not know whether the deceased was or was not subject to a DOLS or whether this made any difference to the care and treatment she required. DOLS application had in fact been in place since August 2015_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
Inquest Conclusion
Whilst there was no evidence in this case that the lack of clarity or knowledge in this particular case made & difference to the deceased, it is important that there is full understanding of the legal status of an individual who is in a care home as this may impact on their care and treatment needs_ ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report, namely by 20.06.2016. I, the coroner; may extend the period: Your response must contain details of action taken Or proposed to be taken; setting out the timetable for action. Otherwise you must explain why no action is proposed: COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mrs Wood am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me, the coroner; at the time ofyour response, about the release or the publication of your response by the Chief Coroner_ 25.04.2016 Joanne Kearsley Area Coroner days
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.